Valley View Rehab: Family Not Told of Head Injury - PA
By the time anyone reached the resident's representative at Valley View Rehab and Nursing Center, staff were already preparing to send the woman to the emergency room.
The resident, identified in inspection records only as Resident CR1, had atrial fibrillation and had been taking Apixaban, sold under the brand name Eliquis, since at least June 2024. Eliquis is an anticoagulant. It prevents blood clots, which is why doctors prescribe it for atrial fibrillation, but it also means that when someone bleeds, the blood doesn't stop as quickly. A head injury in a patient on Eliquis is not a routine fall note. It is a reason to move fast.
The incident happened during a nighttime transfer. Staff were helping the resident move from her wheelchair to the toilet when she bent forward and struck her head on the wall. She developed a three-centimeter by three-centimeter hematoma on her forehead, a pooling of blood beneath the skin, and a skin tear on her right shin.
Nursing staff started neurological checks, the assessments used to evaluate brain function after a head injury. The resident was uncooperative. She would not let staff check her pupils. She would not squeeze their hands. That is not a normal response, and the inspection record does not indicate that anyone called her family at that point.
A second nursing note, written nine minutes after the first, placed the hematoma on the right side of the forehead rather than the left. The injury's location shifted between entries. The record does not explain the discrepancy.
By 10:45 that morning, nearly seven hours after the resident hit her head, a medical provider evaluated her. The documentation noted she had fallen and struck her head, that she was on Eliquis, that she had a hematoma on her right upper forehead, and that she was showing altered mental status. The provider recommended transfer to the emergency room.
Nine minutes later, at 10:54 AM, a nurse called the family. The nursing note from that moment records that staff spoke with the resident's family, who agreed to the transfer. It was the first documented contact with anyone outside the facility about what had happened to her.
Two days later, on December 3, a nurse documented a conversation with the resident's representative. The family member was upset. They said they should have been called when the resident hit her head. They said she should have been sent to the hospital immediately.
There is no record in the inspection findings that the facility disputed this.
State inspectors, conducting a complaint investigation on January 29, 2026, reviewed the closed clinical record and found no evidence of any earlier notification attempt. The administrator and director of nursing were presented with the findings that afternoon.
The inspection cited the facility for failing to immediately notify a resident's responsible party of an accident involving the resident, an accident that resulted in injury and ultimately required physician intervention and emergency transfer. The deficiency was classified as causing minimal harm or potential for actual harm and affected a small number of residents reviewed.
What the classification does not capture is the specific situation the family was placed in. A woman on a blood thinner hit her head hard enough to raise a lump the size of a large postage stamp. She could not cooperate with basic neurological checks in the minutes after it happened. And for nearly seven hours, the people who loved her and were responsible for her care decisions did not know any of it had occurred. They found out when the ambulance was already coming.
The resident's representative told staff she should have been sent to the hospital immediately. Whether earlier notification would have changed the timeline of that transfer, the inspection record does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Valley View Rehab and Nursing Center from 2026-01-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 16, 2026 · Our methodology
VALLEY VIEW REHAB AND NURSING CENTER in MONTOURSVILLE, PA was cited for violations during a health inspection on January 29, 2026.
A head injury in a patient on Eliquis is not a routine fall note.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.